Patients with uncomplicated diverticulitis and comorbidity can be treated at home

Hospital in the home-based management of acute diverticulitis: a safe and effective alternative to inpatient care

BACKGROUND

The traditional approach to management of acute uncomplicated diverticulitis involves admission to hospital, antibiotic therapy, gut rest and monitoring for the development of complications. Despite evidence to suggest this can safely be performed in an outpatient setting, inpatient care remains standard practice in Australia potentially due to a variety of factors (van Dijk et al. 2018; Cirocchi et al. 2019). Hospital in the home (HIH) allows patients requiring complex care including intravenous antibiotics, intravenous fluids and complex pain relief to be managed at home. This study examined the safety and efficacy of HIH-based care for acute diverticulitis over a 16-year period.

METHODOLOGY

A retrospective review of cases of acute diverticulitis managed under our HIH service from the period of 1st of January 2004 to 20th of October 2020 was completed. Baseline descriptive data relating to age, co-morbidities and severity of diverticulitis was collected. Details of medical treatment provided and subsequent complications were also collected.

RESULTS

During the study period, 23 patients with acute diverticulitis were treated under the HIH unit. Among the study population, the median age was 60 (interquartile range 15) with a slight female predominance (n = 13, 56.5%). This represented the first presentation in 60.9% of patients. Average length of stay was 3.6 days (SD = 1.0) with no acute complications recorded in the study period. Two patients (8.7%) had further episodes of acute diverticulitis within 60 days.

CONCLUSION

In this study, the lack of complications demonstrated indicates that HIH-based management of acute diverticulitis may be a viable and safe alternative to inpatient care.

Update on the management of uncomplicated acute diverticulitis at our centre. Equally effective, more efficient

GOALS

The current trend in the treatment of non-complicated diverticulitis is the outpatient management with antibiotic or even anti-inflammatory regimens in selected cases. We present a comparison of the results in our hospital with different protocols applied in 2016 and 2017.

MATERIAL AND METHODS

All patients selected for this study were diagnosed with diverticulitis grade Ia of Hinchey's classification according to radiological findings on abdominal CT. We have analyzed two retrospective cohorts: 100 patients treated in 2016 according to the old protocol and 104 patients treated in 2017 with a new protocol. In 2016, the candidates for ambulatory treatment remained under observation for 24 hours before being discharged. The treatment consisted of 14 days of ciprofloxacin and metronidazole. In 2017, only patients with more acute symptoms were observed 24 hours and amoxicillin-clavulanic acid was prescribed for only 5 days.

RESULTS

The persistence of the disease in 2016 was 6% and in 2017 was only 5.77% (p = 0.944). Recurrence during the first year was 13% in the first group, while in the second it was 5.7%, although this difference was not statistically significant. Likewise, a significant reduction in health costs was achieved.

CONCLUSIONS

Outpatient treatment of acute uncomplicated diverticulitis with oral treatment seems to be a safe and effective therapeutic strategy in selected patients with low comorbidity.

Is the outpatient management of acute diverticulitis safe and effective? A systematic review and meta-analysis

BACKGROUND

In Western countries, the incidence of acute diverticulitis (AD) is increasing. Patients with uncomplicated diverticulitis can undergo a standard antibiotic treatment in an outpatient setting. The aim of this systematic review was to assess the safety and efficacy of the management of acute diverticulitis in an outpatient setting.

METHODS

A literature search was performed on PubMed, Scopus, Embase, Central and Web of Science up to September 2018. Studies including patients who had outpatient management of uncomplicated acute diverticulitis were considered. We manually checked the reference lists of all included studies to identify any additional studies. Primary outcome was the overall failure rates in the outpatient setting. The failure of outpatient setting was defined as any emergency hospital admission in patients who had outpatient treatment for AD in the previous 60 days. A subgroup analysis of failure was performed in patients with AD of the left colon, with or without comorbidities, with previous episodes of AD, in patients with diabetes, with different severity of AD (pericolic air and abdominal abscess), with or without antibiotic treatment, with ambulatory versus home care unit follow-up, with or without protocol and where outpatient management is a common practice. The secondary outcome was the rate of emergency surgical treatment or percutaneous drainage in patients who failed outpatient treatment.

RESULTS

This systematic review included 21 studies including 1781 patients who had outpatient management of AD  including 11 prospective, 9 retrospective and only 1 randomized trial. The meta-analysis showed that outpatient management is safe, and the overall failure rate in an outpatient setting was 4.3% (95% CI 2.6%-6.3%). Localization of diverticulitis is not a selection criterion for an outpatient strategy (p 0.512). The other subgroup analyses did not report any factors that influence the rate of failure: previous episodes of acute diverticulitis (p = 0.163), comorbidities (p = 0.187), pericolic air (p = 0.653), intra-abdominal abscess (p = 0.326), treatment according to a registered protocol (p = 0.078), type of follow-up (p = 0.700), type of antibiotic treatment (p = 0.647) or diabetes (p = 0.610). In patients who failed outpatient treatment, the majority had prolonged antibiotic therapy and only few had percutaneous drainage for an abscess (0.13%) or surgical intervention for perforation (0.06%). These results should be interpreted with some caution because of the low quality of available data.

CONCLUSIONS

The outpatient management of AD can reduce the rate of emergency hospitalizations. This setting is already part of the common clinical practice of many emergency departments, in which a standardized protocol is followed. The data reported suggest that this management is safe if associated with an accurate selection of patients (40%); but no subgroup analysis demonstrated significant differences between groups (such as comorbidities, previous episode, diabetes). The main limitations of the findings of the present review concern their applicability in common clinical practice as it was impossible to identify strict criteria of failure.

The use of the modified Neff classification in the management of acute diverticulitis

INTRODUCTION

Acute diverticulitis (AD) is increasingly seen in Emergency services. The application of a reliable classification is vital for its safe and effective management.

OBJECTIVE

To determine whether the combined use of the modified Neff radiological classification (mNeff) and clinical criteria (systemic inflammatory response syndrome [SIRS] and comorbidity) can ensure safe management of AD.

MATERIAL AND METHODS

Prospective descriptive study in a population of patients diagnosed with AD by computerized tomography (CT). The protocol applied consisted in the application of the mNeff classification and clinical criteria of SIRS and comorbidity to guide the choice of outpatient treatment, admission, drainage or surgery.

RESULTS

The study was carried out from February 2010 to February 2016. A total of 590 episodes of AD were considered: 271 women and 319 men, with a median age of 60 years (range: 25-92 years). mNeff grades were as follows: grade 0 (408 patients 70.6%); 376/408 (92%) were considered for home treatment; of these 376 patients, 254 (67.5%) were discharged and controlled by the Home Hospitalization Unit; 33 returned to the Emergency Room for consultation and 22 were re-admitted; the success rate was 91%. Grade Ia (52, 8.9%): 31/52 (59.6%) were considered for outpatient treatment; of these 31 patients, 11 (35.5%) were discharged; eight patients returned to the Emergency Room for consultation and five were re-admitted. Grade Ib (49, 8.5%): five surgery and two drainage. Grade II (30, 5.2%): ten surgery and four drainage. Grade III (5, 0.9%): one surgery and one drainage. Grade IV (34, 5.9%): ten patients showed good evolution with conservative treatment. Of the 34 grade IV patients, 24 (70.6%) underwent surgery, and three (8.8%) received percutaneous drainage.

CONCLUSIONS

The mNeff classification is a safe, easy-to-apply classification based on CT findings. Together with clinical data and comorbidity data, it allows better management of AD.

A systematic review and meta-analysis of outpatient treatment for acute diverticulitis

BACKGROUND

The shift from routine antibiotics towards omitting antibiotics for uncomplicated acute diverticulitis opens up the possibility for outpatient instead of inpatient treatment, potentially reducing the burden of one of the most common gastrointestinal diseases in the Western world.

PURPOSE

Assessing the safety and cost savings of outpatient treatment in acute colonic diverticulitis.

METHODS

PubMed and EMBASE were searched for studies on outpatient treatment of colonic diverticulitis, confirmed with computed tomography or ultrasound. Outcomes were readmission rate, need for emergency surgery or percutaneous abscess drainage, and healthcare costs.

RESULTS

A total of 19 studies with 2303 outpatient treated patients were included. These studies predominantly excluded patients with comorbidity or immunosuppression, inability to tolerate oral intake, or lack of an adequate social network. The pooled incidence rate of readmission for outpatient treatment was 7% (95%CI 6-9%, I² 48%). Only 0.2% (2/1288) of patients underwent emergency surgery, and 0.2% (2/1082) of patients underwent percutaneous abscess drainage. Only two studies compared readmission rates outpatients that had similar characteristics as a control group of inpatients; 4.5% (3/66) and 6.3% (2/32) readmissions in outpatient groups versus 6.1% (4/66) and 0.0% (0/44) readmissions in inpatient groups (p = 0.619 and p = 0.174, respectively). Average healthcare cost savings for outpatient compared with inpatient treatment ranged between 42 and 82%.

CONCLUSION

Outpatient treatment of uncomplicated diverticulitis resulted in low readmission rates and very low rates of complications. Furthermore, healthcare cost savings were substantial. Therefore, outpatient treatment of uncomplicated diverticulitis seems to be a safe option for most patients.

Early Discharge Programme on Hospital-at-Home Evaluation for Patients with Immediate Postoperative Course after Laparoscopic Colorectal Surgery

BACKGROUND

To audit the safety of the early hospital discharge care model offered by a Hospital-at-home (HAH) unit during early postoperative follow-up of these patients, and to determine whether this care model is more efficient compared to the traditional care model.

METHODS

A prospective study of 50 patients included consecutively for 1 year in an early discharge programme after laparoscopic colorectal surgery was performed. As of day 3 after surgery, if the patient met the relevant inclusion criteria they were transferred to the HAH unit. The domiciliary protocol consists of daily clinical follow-up and a series of analytical controls with the purpose of early detection of postoperative complications. If the clinical course was favourable on day 7 after the postoperative period the patient was discharged.

RESULTS

A total of 66% were males, and the mean age was 60.6 years. The surgical procedure most commonly performed was sigmoidectomy. The mean stay was 5.5 days. There were no deaths during follow-up. The average estimated cost per day of stay in a HAH system was EUR 174.29 whilst the same average cost on a surgery ward stood at EUR 1,032.42.

CONCLUSIONS

For patients undergoing major colorectal surgery with minimally invasive surgical technique, an early hospital discharge care programme by means of referral to a HAH unit is a safe and efficient care model which entails a significant cost saving for the public healthcare system.

Clinical and cost-effectiveness, safety and acceptability of community intravenous antibiotic service models: CIVAS systematic review

OBJECTIVE

Evaluate evidence of the efficacy, safety, acceptability and cost-effectiveness of outpatient parenteral antimicrobial therapy (OPAT) models.

DESIGN

A systematic review.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, Cochrane Library, National Health Service (NHS) Economic Evaluation Database (EED), Research Papers in Economics (RePEc), Tufts Cost-Effectiveness Analysis (CEA) Registry, Health Business Elite, Health Information Management Consortium (HMIC), Web of Science Proceedings, International Pharmaceutical Abstracts, British Society for Antimicrobial Chemotherapy website. Searches were undertaken from 1993 to 2015.

STUDY SELECTION

All studies, except case reports, considering adult patients or practitioners involved in the delivery of OPAT were included. Studies combining outcomes for adults and children or non-intravenous (IV) and IV antibiotic groups were excluded, as were those focused on process of delivery or clinical effectiveness of 1 antibiotic over another. Titles/abstracts were screened by 1 reviewer (20% verified). 2 authors independently screened studies for inclusion.

RESULTS

128 studies involving >60 000 OPAT episodes were included. 22 studies (17%) did not indicate the OPAT model used; only 29 involved a comparator (23%). There was little difference in duration of OPAT treatment compared with inpatient therapy, and overall OPAT appeared to produce superior cure/improvement rates. However, when models were considered individually, outpatient delivery appeared to be less effective, and self-administration and specialist nurse delivery more effective. Drug side effects, deaths and hospital readmissions were similar to those for inpatient treatment, but there were more line-related complications. Patient satisfaction was high, with advantages seen in being able to resume daily activities and having greater freedom and control. However, most professionals perceived challenges in providing OPAT.

CONCLUSIONS

There were no systematic differences related to the impact of OPAT on treatment duration or adverse events. However, evidence of its clinical benefit compared with traditional inpatient treatment is lacking, primarily due to the dearth of good quality comparative studies. There was high patient satisfaction with OPAT use but the few studies considering practitioner acceptability highlighted organisational and logistic barriers to its delivery.

The Community IntraVenous Antibiotic Study (CIVAS): a mixed-methods evaluation of patient preferences for and cost-effectiveness of different service models for delivering outpatient parenteral antimicrobial therapy

Background

Outpatient parenteral antimicrobial therapy (OPAT) is widely used in most developed countries, providing considerable opportunities for improved cost savings. However, it is implemented only partially in the UK, using a variety of service models.

Objectives

The aims of this research were to (1) establish the extent of OPAT service models in England and identify their development; (2) evaluate patients’ preferences for different OPAT service delivery models; (3) assess the cost-effectiveness of different OPAT service delivery models; and (4) convene a consensus panel to consider our evidence and make recommendations.

Methods

This mixed-methods study included seven centres providing OPAT using four main service models: (1) hospital outpatient (HO) attendance; (2) specialist nurse (SN) visiting at home; (3) general nurse (GN) visiting at home; and (4) self-administration (SA) or carer administration. Health-care providers were surveyed and interviewed to explore the implementation of OPAT services in England. OPAT patients were interviewed to determine key service attributes to develop a discrete choice experiment (DCE). This was used to perform a quantitative analysis of their preferences and attitudes. Anonymised OPAT case data were used to model cost-effectiveness with both Markov and simulation modelling methods. An expert panel reviewed the evidence and made recommendations for future service provision and further research.

Results

The systematic review revealed limited robust literature but suggested that HO is least effective and SN is most effective. Qualitative study participants felt that different models of care were suited to different types of patient and they also identified key service attributes. The DCE indicated that type of service was the most important factor, with SN being strongly preferred to HO and SA. Preferences were influenced by attitudes to health care. The results from both Markov and simulation models suggest that a SN model is the optimal service for short treatment courses (up to 7 days). Net monetary benefit (NMB) values for HO, GN and SN services were £2493, £2547 and £2655, respectively. For longer treatment, SA appears to be optimal, although SNs provide slightly higher benefits at increased cost. NMB values for HO, GN, SN and SA services were £8240, £9550, £10,388 and £10,644, respectively. The simulation model provided useful information for planning OPAT services. The expert panel requested more guidance for service providers and commissioners. Overall, they agreed that mixed service models were preferable.

Limitations

Recruitment to the qualitative study was suboptimal in the very elderly and ethnic minorities, so the preferences of patients from these groups might not be represented. The study recruited from Yorkshire, so the findings may not be applicable nationally.

Conclusions

The quantitative preference analysis and economic modelling favoured a SN model, although there are differences between sociodemographic groups. SA provides cost savings for long-term treatment but is not appropriate for all.

Future work

Further research is necessary to replicate our results in other regions and populations and to evaluate mixed service models. The simulation modelling and DCE methods used here may be applicable in other health-care settings.

Funding

The National Institute for Health Research Health Service and Delivery Research programme.

Outpatient treatment of uncomplicated diverticulitis: a systematic review

Acute diverticulitis occurs in up to 25% of patients with diverticulosis. The majority of cases are mild or uncomplicated and it has become a frequent reason for consultation in the emergency department. On the basis of the National Inpatient Sample database from the USA, 86% of patients admitted with diverticulitis were treated with medical therapy. However, several recent studies have shown that outpatient treatment with antibiotics is safe and effective. The aim of this systematic review is to update the evidence published in the outpatient treatment of uncomplicated acute diverticulitis. We performed a systematic review according to the PRISMA guidelines and searched in MEDLINE and Cochrane databases all English-language articles on the management of acute diverticulitis using the following search terms: 'diverticulitis', 'outpatient', and 'uncomplicated'. Data were extracted independently by two investigators. A total of 11 articles for full review were yielded: one randomized controlled trial, eight prospective cohort studies, and two retrospective cohort studies. Treatment successful rate on an outpatient basis, which means that no further complications were reported, ranged from 91.5 to 100%. Fewer than 8% of patients were readmitted in the hospital. Intolerance to oral intake and lack of family or social support are common exclusion criteria used for this approach, whereas severe comorbidities are not definitive exclusion criteria in all the studies. Ambulatory treatment of uncomplicated acute diverticulitis is safe, effective, and economically efficient when applying an appropriate selection in most reviewed studies.

Patient-reported Outcomes After Conservative or Surgical Management of Recurrent and Chronic Complaints of Diverticulitis: Systematic Review and Meta-analysis

BACKGROUND & AIMS

Patients with diverticulitis develop recurrences and chronic abdominal symptoms. Recurrent diverticulitis is seldom complicated, which has led to a conservative treatment approach. However, some studies suggest that surgical intervention reduces recurrence and chronic abdominal problems. We conducted a systematic review and meta-analysis of quality of life (QOL) and other patient-reported outcomes (PROs) after conservative vs surgical treatment of uncomplicated diverticulitis.

METHODS

We searched the CENTRAL, MEDLINE, EMBASE, and PsycInfo databases for randomized trials and cohort studies reporting on QOL or other PROs after conservative or operative treatment for uncomplicated diverticulitis from January 1990 through May 2014. Eight PROs were defined and graded according to their clinical relevance. Risk of bias was assessed by using the Cochrane Collaboration tool. Subgroup and sensitivity analyses were performed to test the robustness of the results. The review protocol was registered through PROSPERO (CRD42013005854).

RESULTS

We analyzed data from 21 studies that comprised 1858 patients; all studies had a high risk of bias. There were no head-to-head comparisons of gastrointestinal symptoms or general QOL between elective surgical vs conservative treatment of recurrent diverticulitis. On the basis of Short-Form 36 scores, patients had higher QOL scores after elective laparoscopic resection (73.4; 95% confidence interval [CI], 65.7-81.1) than conservative treatment (58.1; 95% CI, 47.2-69.1). A lower proportion of patients had gastrointestinal symptoms after laparoscopic surgery (9%; 95% CI, 4%-14%) than conservative treatment (36%; 95% CI, 27%-45%) in all cohorts and in 1 trial comparing these treatments (odds ratio, 0.35; 95% CI, 0.16-0.7). The proportion of patients with chronic abdominal pain after elective laparoscopy was 11% (95% CI, 1%-21%) compared with 38% (95% CI, 19%-56%) after conservative treatment.

CONCLUSIONS

On the basis of a systematic review and meta-analysis, patients have better QOL and fewer symptoms after laparoscopic surgery vs conservative treatment. However, studies of PROs for treatment of diverticulitis were of low quality.

Self-administered outpatient parenteral antimicrobial therapy (S-OPAT) for infective endocarditis: a safe and effective model

The safety and efficacy of treatment of infectious endocarditis (IE) was evaluated within a program of hospital-in-home (HIH) based on self-administered outpatient parenteral antimicrobial therapy (S-OPAT). IE episodes (n=48 in 45 patients; 71% middle-aged males) were recruited into the HIH program between 1998 and 2012. Following treatment stabilization at the hospital they returned home for HIH in which a physician and/or a nurse supervised the S-OPAT. Safety and efficacy were evaluated as mortality, re-occurrence, and unexpected re-admission to hospital. Of the episodes of IE, 83.3% had comorbidities with a mean score of 2.3 on the Charlson index and 1.5 on the Profund index; 60.4% had pre-existing valve disease (58.6% having had surgical intervention); 8.3% of patients had suffered a previous IE episode; 62.5% of all episodes affected a native valve; 45.8% being mitral; 70.8% of infection derived from the community. In 75% of the episodes there was micro-organism growth, of which 83.3% were Gram positive. Overall duration of antibiotic treatment was 4.8 weeks; 60.4% of this time corresponding to HIH. Re-admission occurred in 12.5% of episodes of which 33.3% returned to HIH to complete the S-OPAT. No deaths occurred during HIH. One year after discharge, 2 patients had recurrence and 5 patients died, in 2 of whom previous IE as cause-of-death could not be excluded. In conclusion, the S-OPAT schedule of hospital-in-home is safe and efficacious in selected patients with IE.

Systematic review: outpatient management of acute uncomplicated diverticulitis

PURPOSE OF REVIEW

Acute uncomplicated diverticulitis is traditionally managed by inpatient admission for bowel rest, intravenous fluids and intravenous antibiotics. In recent years, an increasing number of publications have sought to determine whether care might instead be conducted in the community, with earlier enteral feeding and oral antibiotics. This systematic review evaluates the safety and efficacy of such an ambulatory approach.

METHODS

Medline, Embase and Cochrane Library databases were searched. All peer-reviewed studies that investigated the role of ambulatory treatment protocols for acute uncomplicated diverticulitis, either directly or indirectly, were eligible for inclusion.

RESULTS

Nine studies were identified as being suitable for inclusion, including one randomised controlled trial, seven prospective cohort studies and one retrospective cohort study. All, except one, employed imaging as part of their diagnostic criteria. There was inconsistency between studies with regards to whether patients with significant co-morbidities were eligible for ambulatory care and whether bowel rest therapy was employed. Neither of these variables influenced outcome. Across all studies, 403 out of a total of 415 (97 %) participants were successfully treated for an episode of acute uncomplicated diverticulitis using an outpatient-type approach. Cost savings ranged from 35.0 to 83.0 %.

CONCLUSION

Current evidence suggests that a more progressive, ambulatory-based approach to the majority of cases of acute uncomplicated diverticulitis is justified. Based on this evidence, the authors present a possible outpatient-based treatment algorithm. An appropriately powered randomised controlled trial is now required to determine its safety and efficacy compared to traditional inpatient management.

A randomized controlled trial of home monitoring versus hospitalization for mild non-alcoholic acute interstitial pancreatitis: a pilot study

BACKGROUND/OBJECTIVES

Acute pancreatitis (AP) is a disease typically requiring in-hospital treatment. We conducted a trial to assess the feasibility of early discharge from the hospital for patients with mild non-alcoholic acute pancreatitis (NAAP).

METHODS

Eighty-four patients with mild NAAP were randomized to home or hospital groups after a short hospital stay (≤24 h). AP was defined by the revised Atlanta criteria. Mild AP was defined as an Imrie score≤5 and a harmless acute pancreatitis score (HAPS)≤2 in the first 24-h of presentation. A nurse visited all patients in the home group on the 2nd, 3rd and 5th days. All patients presented for follow-up in clinic on the 7th, 14th, and 30th days. The primary outcome was the time to resolution of pain. Secondary outcomes evaluated included time to resumption of an oral diet, 30 day hospital readmission rate as well as the total costs associated with either approach to care.

RESULTS

There was no difference between the groups with regards to demographics, prognostic severity scores, symptoms, and biliary findings. No patients developed organ failure, pancreatic necrosis, or died in either group. Time to the resolution of pain and resumption of solid food intake were similar. Three (3.6%) patients required readmission within 30 days, 1 from home and 2 from the hospital groups. The total cost was significantly less in home group ($139 ± 73 vs. $951 ± 715,p < 0.001).

CONCLUSIONS

Mild NAAP can be safely treated at home with regular visits by a nurse under the supervision of a physician. Widespread adoption of this practice may result in large cost savings.

Home treatment of uncomplicated acute diverticulitis

Diverticular disease of the colon is a common disease, mainly in the population over 50 years of age. In acute forms of presentation, we considered home treatment in those patients that were classified as having uncomplicated forms by means of clinical presentation and a computed tomography of the abdomen. According to these criteria, we treated 38 patients at home and admitted 18 patients to the hospital during the same period of time. No severe complications developed in the home-treatment patients. Home treatment is an effective alternative treatment for patients with uncomplicated acute diverticulitis. In uncomplicated acute diverticulitis, home treatment benefits the patient, over hospitalization, by allowing better management of resources and by keeping the patient in a familiar environment where there is no risk of a nosocomial infection.

Review article: The pathogenesis and management of acute colonic diverticulitis

BACKGROUND

Acute diverticulitis, defined as acute inflammation associated with a colonic diverticulum, is a common emergency presentation managed by both surgeons and physicians. There have been advances in both the medical and the surgical treatments offered to patients in recent years.

AIM

To review the current understanding of the aetiology and treatment of acute diverticulitis.

METHODS

A search of PubMed and Medline databases was performed to identify articles relevant to the aetiology, pathogenesis and management of acute diverticulitis.

RESULTS

There are 75 hospital admissions per year for acute diverticulitis per 100,000 of the population in the United States. Recent reports suggest a 26% increase in admissions over a 7-year period. Factors predisposing to the development of acute diverticulitis include obesity, smoking, diet, lack of physical activity and medication use such as aspirin and nonsteroidal anti-inflammatory drugs. The condition is associated with a low mortality of about 1% following medical therapy, rising to 4% in-hospital mortality in those requiring surgery. There is limited evidence on the efficacy of individual antibiotic regimens, and antibiotic treatment may not be required in all patients. The rates of recurrence reported for patients with acute diverticulitis following medical management vary from 13% to 36%. The surgical management of those patients who fail medical treatment has moved towards a laparoscopic nonresectional approach; however, the evidence supporting this is limited.

CONCLUSIONS

Further high-quality randomised controlled trials are required of both medical and surgical treatments in patients with acute diverticulitis, if management is to be evidence-based.

Outpatient treatment for acute uncomplicated diverticulitis

BACKGROUND

Traditionally, treatment of acute diverticulitis has mostly been based on inpatient care. The question arises whether these patients can be treated on an outpatient basis as the admissions for diverticular disease have been shown to be increasing every year. We studied whether outpatient treatment of acute uncomplicated diverticulitis is feasible and safe, and which patients could benefit from outpatient care.

MATERIALS AND METHODS

A retrospective cohort study was carried out in two teaching hospitals using hospital registry codes for diverticulitis. All patients diagnosed with acute uncomplicated diverticulitis between January 2004 and January 2012, confirmed by imaging or colonoscopy, were included. Exclusion criteria were patients with recurrent diverticulitis, complicated diverticulitis (Hinchey stages 2, 3, and 4), and right-sided diverticulitis. Inpatient care was compared with outpatient care. Primary outcome was admission for outpatient care and the complication rate in both groups. Multivariate analysis was carried out to identify potential factors for inpatient care.

RESULTS

Of 627 patients with diverticulitis, a total of 312 consecutive patients were identified with primary uncomplicated diverticulitis of the sigmoid colon; 194 patients had been treated as inpatients and 118 patients primarily as outpatients. In this last group, 91.5% had been treated successfully without diverticulitis-related complications or the need for hospital admission during a mean follow-up period of 48 months.

CONCLUSION

Despite inherent patient selection in a retrospective cohort, ambulatory treatment of patients presenting with uncomplicated acute diverticulitis seems feasible and safe. In mildly ill and younger patients, hospital admission can be avoided.

Treatment of elderly patients with uncomplicated diverticulitis, even with comorbidity, at home

BACKGROUND

Elderly patients with uncomplicated diverticulitis are usually hospitalized. The aim of this study is to compare the outcomes of elderly patients with uncomplicated diverticulitis who were treated at home versus traditional Hospitalization.

METHODS

Prospective study from March 2011 to September 2012 including patients over 70 years with uncomplicated diverticulitis admitted to Hospital at Home Unit and to Conventional Hospitalization from the Emergency Department. Patients with β-lactam allergy or who required admission to Conventional Hospitalization for other pathology were excluded. All patients were given intravenous antibiotic. Patients transferred to Hospital at Home stayed 24h in the Observation Ward within the Emergency Department prior to discharge. Characteristics and outcomes of patients are analyzed.

RESULTS

34 patients were treated at home and 18 in hospital. Mean age was similar in both groups (77 vs 79). The oldest patient treated at home was 90 years old. 64% of patients treated in Hospital at Home had comorbidity vs 68% in Conventional Hospitalization. 11% of patients treated at home were diabetic. Thickening colonic wall was present in 100% of patients. 38% of patients treated at home had free fluid vs 42% treated in Hospital. All patients had a good clinical evolution. None of the patients treated at home was transferred to Hospital. Home treatment was associated with a cost reduction of 1368 euros per patient.

CONCLUSIONS

Treatment at home of elderly patients with uncomplicated diverticulitis is as safe and effective as treatment in Hospital, even if patient has comorbidity.

[Outpatient treatment of uncomplicated acute diverticulitis: Impact on healthcare costs]

BACKGROUND

Outpatient treatment of uncomplicated acute diverticulitis is safe and effective. The aim of this study was to determine the impact of outpatient treatment on the reduction of healthcare costs.

PATIENTS AND METHODS

A retrospective cohort study comparing 2 groups was performed. In the outpatient treatment group, patients diagnosed with uncomplicated acute diverticulitis were treated with oral antibiotics at home. In the hospital treatment group, patients met the criteria for outpatient treatment but were admitted to hospital and received intravenous antibiotic therapy. Cost estimates have been made using the hospital cost accounting system based on total costs, the sum of all variable costs (direct costs) plus overhead expenses divided by activity (indirect costs).

RESULTS

A total of 136 patients were included, 90 in the outpatient treatment group and 46 in the hospital group. There were no differences in the characteristics of the patients in both groups. There were also no differences in the treatment failure rate in both groups (5.5% vs. 4.3%; P=.7). The total cost per episode was significantly lower in the outpatient treatment group (882 ± 462 vs. 2.376 ± 830 euros; P=.0001).

CONCLUSIONS

Outpatient treatment of acute diverticulitis is not only safe and effective but also reduces healthcare costs by more than 60%.